CurrentIllinois Department of Healthcare and Family ServicesPolicy N/A
Durable Medical Equipment and Supplies Fee Schedule
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This document provides the Illinois Department of Healthcare and Family Services fee schedule (prices, quantity limits, rental/purchase designation, Medicare coverage indicators, and prior authorization flags) for durable medical equipment and supplies effective 01/01/2026 (updated 04/01/2026). It affects providers billing HFS for DME and related supplies.
Policy Summary
PayerIllinois Department of Healthcare and Family Services
PolicyDurable Medical Equipment and Supplies Fee Schedule
Policy CodePolicy N/A
Change TypeAdministrative fee-schedule update (no material clinical coverage changes)
Effective DateJan 1, 2026
Last ReviewApr 1, 2026
Next Review DateApr 1, 2026
Key ActionWhen billing HFS for DME/supplies, reference each HCPCS line for its purchase/rent price, Max Qty/Max Days, Medicare coverage flag, and COS/PA H/P indicators.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
2.7%uniform price reduction applied to listed prices
multipleline-item entries (partial listing in this part)
MaxQty/MaxDaysper-line quantity and days limits included
Medicare flagMedicare coverage indicator present for many items
~200+fee-schedule entries in this extract
Fee-Schedule Coverage, Pricing, and Utilization Constraints
Fee-schedule encoded coverage/billing fields
Per-line coverage/billing stance encoded in fields:
Medicare Covered** — indicator whether Medicare covers purchase of the item (Y/N) appears on each line.
Purchase Price / Rent Price — price fields provided per line with a corresponding '2.7% Reduced Purchase Price' (and reduced rent where applicable).
PA Req H/P — prior authorization required for hospital/provider or home/patient contexts; shown as Y/N per line or with COS codes (e.g., 048, 041).
COS PA Req — Certificate of Service / prior-authorization code field (examples: '048', '041') present per HCPCS line.
LTC Pair — long-term care pairing indicator with optional paired price for LTC billing contexts (Y/N and paired price where shown).
Max Qty / Max Days — per-line utilization limits specifying maximum quantity and maximum days allowed per code (common values include 1/30, 2/30, 10/30, 4/180, 1/365, etc.).
Examples of coverage/limits from the extract
Per-item coverage indicators and limits (representative examples from the extract):
Coverage and pricing entries (excerpt)
Pricing and coverage flags for listed HCPCS items in this excerpt:
Purchase and reduced purchase prices are shown per line; rent prices and reduced rent shown where applicable (fee schedule applies a uniform 2.7% reduction unless noted).
Per-line PA indicators (PA Req H/P) and COS PA Req codes appear in the rows (values include N, Y, and codes such as 048).
Max Qty / Max Days values are included per HCPCS line (examples in this excerpt include 2/30, 30/30, 1/60).
Example item coverage/limits
Example item-level coverage/administrative attributes present in the fee schedule excerpt:
A4396 (example in extract) — ostomy belt: Medicare purchase indicated; purchase price and 2.7% reduced purchase price shown; LTC Pair price shown when applicable; PA Req H/P set to N; Max Qty/Max Days example 4 / 180.
Ostomy supplies coverage entries (excerpt)
Ostomy supplies: line-item coverage and limitations (selected rows):
A4410 — ostomy skin barrier w/flange (>4x4): LTC Pair = Y; Medicare Covered** Purchase shown with purchase and 2.7% reduced price; Max Qty / Max Days = 10 / 30; PA indicators = N.
A4411 — ostomy skin barrier solid 4x4: LTC Pair = Y; Medicare Covered** Purchase with purchase and reduced price; Max Qty / Max Days = 4 / 30; PA indicators = N.
A4412 — ostomy pouch, drainable high-output (2-piece): LTC Pair = Y; Medicare Covered** Purchase and 2.7% reduced price; Max Qty / Max Days = 20 / 30; PA indicators = N.
Per-item coverage and billing rules (partial)
Per-item coverage and billing parameters (partial; selected examples):
A4425 — ostomy pouch, drainable, use with barrier w/non-lock: COS PA Req = N; PA Req H/P shown as N Y N Y patterns; LTC Pair price and Medicare Covered** Purchase listed; purchase price and 2.7% reduced purchase price shown; Max Qty / Max Days = 20 / 30.
A4434–A4450 (group example) — ostomy pouch urinary and tape items: purchase prices and reduced prices listed; Max Qty/Max Days examples include 120 / 30 for tape; COS/PA/H/P flags included per line.
A4450–A4453 — rectal catheter / TAI system items: purchase prices with 2.7% reduced values; Max Qty / Max Days examples (e.g., 90 / 90) and COS/PA flags present.
A4555–A4563 — assorted tracheostomy/stoma supplies, electrodes, conductive paste, pessaries: per-line purchase prices and reduced prices, COS/PA indicators, and Max Qty/Max Days as listed.
Sample code-level coverage entries
Example coverage and limits for specific codes:
A4605 — tracheal suction catheter, closed system: COS PA Req = 048; PA Req H/P = N; H/P LTC Pair = Y; Medicare Covered** Purchase = N (purchase price shown $17.06); 2.7% Reduced Purchase Price = $16.60; Max Qty / Max Days = 30 / 30.
Ostomy pouch items
Ostomy pouch coverage/pricing examples (selected):
A5052 — ostomy pouch, closed with barrier attached: Medicare Covered** Purchase = Y; purchase price and 2.7% reduced purchase price shown (example $2.03 → $1.98); Max Qty / Max Days = 60 / 30.
A5057 — ostomy pouch drainable or with built-in convex: Medicare Covered** Purchase = Y; example purchase and reduced prices shown ($10.09 → $9.82); Max Qty / Max Days = 20 / 30.
Extracted sample item coverage rows
Extracted sample item coverage rows (selected examples):
A5054 — ostomy pouch, closed for use on barrier w/flange: COS PA Req = 048; PA Req H/P = N; H/P LTC Pair varies; Medicare Covered** Purchase = Y; purchase and reduced prices shown (e.g., $1.64 → $1.60); Max Qty / Max Days = 60 / 30 or 30 / 30 depending on variant.
A5501 — custom diabetic shoe example: Medicare Covered** Purchase = Y; purchase and reduced prices listed ($229.71 → $223.51); COS PA Req may be '041'; Max Qty / Max Days = 2 / 365.
A6021 — collagen dressing, pad size ≤16 sq in: Medicare Covered** Purchase = Y; purchase and reduced prices shown ($20.55 → $20.00); COS PA Req = 048; Max Qty / Max Days = 30 / 30.
Fee schedule item coverage and pricing
Fee schedule item coverage and pricing (stance and item-level notes):
Each HCPCS line lists a purchase price and a '2.7% Reduced Purchase Price' value; rent price and reduced rent price included where applicable.
'Medicare Covered** Purchase' field marks whether Medicare covers purchase of the item; when 'Y' a Medicare purchase price is shown.
Most entries provide Max Qty and Max Days values (commonly 12, 30, 60, 90, 180); these utilization limits are specified per line.
Pricing, authorization, and utilization constraints
Pricing, authorization, and utilization constraints (per-line billing stance):
Price fields — purchase and reduced purchase prices included per line; some lines also list rent price and reduced rent price.
Authorization flags — 'COS PA Req' and 'PA Req H/P' flags indicate whether a Certificate of Service or prior authorization (and whether history/physical) is required; values include codes (e.g., 048, 041) and Y/N.
Utilization limits — 'Max Qty / Max Days' shown for most items with common examples across the schedule (e.g., 12/30, 30/30, 4/180, 1/365).
Line-item coverage & billing rules
Line-item coverage & billing rules (selected segments):
A6441–A6444 and similar bandage/ dressing lines — Medicare Covered** Purchase flags present; 2.7% reduced purchase prices shown; Max Qty / Max Days examples include 90 and 180 days for some bandages.
A6501–A6513 (compression/custom garments) — COS PA Req and PA Req H/P often set to '041' or 'Y' indicating PA requirements for custom/compression items; Medicare coverage and pair flags vary; example Max Qty / Max Days = 4 / 180.
A7000–A7033 (therapy/CPAP items) — COS PA Req = 041 for many CPAP/therapy components; Medicare Covered** Purchase prices and 2.7% reduced prices listed; Max Qty / Max Days examples include 1–3 per 365 days depending on item.
Per-HCPCS coverage attributes
Per-HCPCS coverage attributes (examples across code groups):
A6513 — compression burn mask / gradient compression stocking entries: PA Req H/P = Y for some variants; Medicare Covered** Purchase and reduced prices shown ($17.99 → $17.50 examples); Pair/LTC and Max Qty/Max Days fields present.
A6531–A6532 — gradient compression stocking examples: COS PA Req = 041; PA Req H/P = N; Pair and Medicare Covered flags shown with purchase and reduced prices; Max Qty / Max Days = 4 / 180.
Per-item coverage and limits (examples)
Per-item coverage and limits (examples across categories):
A7028 — nasal pillows for CPAP: COS PA Req = 041; PA Req H/P = N; H/P LTC Pair = Y; Medicare Covered** Purchase prices listed with 2.7% reduced values; Max Qty / Max Days = 2 / 365 or 3 / 365 depending on variant.
A7035 — CPAP headgear/parts: purchase and reduced purchase prices listed (e.g., $115.00 → $111.90); Max Qty / Max Days examples include 1 / 180 or 2 / 365.
Coverage indicators and billing constraints
Coverage indicators and billing constraints (summary of visible flags and limits):
Medicare Covered** Purchase — Y/N indicator present per line; when 'Y' a Medicare purchase price is listed alongside a 2.7% reduced purchase price.
2.7% Reduced Purchase Price — uniform reduction applied to listed purchase (and sometimes rent) prices; reduced values shown next to base prices.
COS PA Req / PA Req H/P — administrative flags per line indicating certificate-of-service and prior-authorization requirements; values include codes (e.g., 048, 041) and simple N/Y indicators.
Max Qty / Max Days — utilization constraints provided for most items and vary by code; examples include 1/30, 2/30, 4/365, 60/30, 1/1095 depending on item.
Per-item coverage/payment attributes
Per-item coverage/payment attributes (fields present on each fee line):
Code and description — HCPCS-like code and item description appear per row.
Medicare Covered** Purchase — Y/N flag with purchase price when 'Y'.
Purchase Price and 2.7% Reduced Purchase Price — base and reduced purchase pricing provided; Rent Price and reduced rent shown where applicable.
COS PA Req / PA Req H/P — prior authorization or Certificate of Service indicators (codes and Y/N values) included per item.
Max Qty / Max Days — per-line utilization limits specifying allowed quantity and allowed days for the billing period; values vary by item (examples: 1/365, 1/1095, 2/365).
HCPCS/DME Codes, Prices, and Quantity Limits (sample rows)
HCPCS items in extractHCPCSCovered
| A4311-A4313 (range shown in extract) | INSERTION TRAY W/O DRAINAGE BAG, WITH FOLEY CATH; related insertion trays as listed in this partial fee schedule. |
Ostomy supply HCPCS codes in excerptHCPCSCovered
| A4408 | OST SKIN BARR.W/FLANG EX WEAR BUILT-IN CONVEX >4X4 |
| A4409 | OST SKIN BARR W/FLANGE EX WEAR W/O CONVEX -/= |
| A4410 | OST SKIN BARR W/FLANGE EX WEAR W/O CONVEX > 4X4 |
| A4411 | OSTOMY SKIN BARRIER SOLID 4X4 OR EQUIV EXT WEAR |
| A4412 | OSTOMY POUCH, DRAINABLE, HIGH OUTPUT/2-PIECE (line) |
| A4413 | OSTOMY POUCH, DRAINABLE HIGH OUTPUT USE WITH 2-PIECE SYSTEM |
| A4414 | OST SKIN BARRIER W/FLANGE WITHOUT BUILT-IN CONVEX <=4X4 |
| A4415 | OST SKIN BARRIER W/FLANGE WITHOUT BUILT-IN CONVEX >4X4 |
| A4416 | OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH FILTER |
| A4417 | OSTOMY POUCH CLOSED WITH BUILT-IN CONVEX BARRIER, WITH FILTER |
1–10 of 20
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Ostomy supply HCPCS codes in excerpt (additional)HCPCSCovered
| A5052 | OSTOMY POUCH, CLOSED; W/BARRIER ATTACHED (1 PC) |
| A5053 | OSTOMY POUCH; related item (see row for specific descriptor and pricing) |
| A5054 | OSTOMY POUCH, CLOSED; FOR USE ON BARRIER W/FLANGE |
| A5055 | STOMA CAP OSTOMY POUCH DRAIN W/EXT WEAR BARRIER W FILTER |
| A5056 | STOMA CAP / OSTOMY POUCH DRAIN W/EXT WEAR BARRIER W FILTER (variant) |
| A5057 | OSTOMY POUCH DRAIN W/EXT WEAR BARRIER W FILTER; drainable with built-in convex (example) |
| A5061 | OSTOMY POUCH, DRAINABLE; W/BARRIER (1 PC) EACH |
| A4425 | OSTOMY POUCH, DRAINABLE, USE W/BARRIER W/NON-LOCK |
| A4426 | OSTOMY POUCH, DRAINABLE, USE ON BARRIER W/LOCK FLANGE |
| A4427 | OSTOMY POUCH, DRAIN, USE BARRIER W/LOCK, W/FILTER |
1–10 of 20
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HCPCS code list (partial)HCPCSCovered
| A4424-A4563 (range represented) | HCPCS codes for ostomy supplies, tapes, catheters, TAI systems, electrodes/leads, conductive gel, pessary and related DME supplies shown in this window |
Representative HCPCS lines in excerptHCPCSCovered
HCPCS code group (wound care supply range shown)HCPCS | mixedCovered
| A6022-A6236 (examples) | HCPCS-like fee schedule codes for wound dressings and related supplies (sequence of A6xxx codes shown in this segment) |
HCPCS codes in this segmentHCPCSCovered
| A6441-A6443 (partial) | Bandage pads, conforming bandages and related dressing items listed in this segment |
Sample HCPCS items (partial list)HCPCSCovered
Example quantity/day limits — common entries
Example (A4212)Max Qty 15 / Max Days 30
Example (A4311)Max Qty 1 / Max Days 30
Example (A4351)Max Qty 200 / Max Days 30
Max quantity / Max days per billing unit
1/30Example: insertion trays and many ostomy items (Max Qty 1 per 30 days)
2/30Example: bedside urine drain bags listed as 2 per 30 days
200/30Example: intermittent urinary catheter (A4351) Max Qty 200 per 30 days
Max quantity / Max days — per-line examples
2/30BEDSIDE URIN DRAIN BAG and similar (Max Qty 2 / Max Days 30)
1/90Some ostomy irrigation bags listed as 1 / 90 days (e.g., A4398–A4400 entries)
4/180Ostomy belt with peristomal hernia support: Max Qty 4 / Max Days 180
Max quantity / Max days — explicit examples
10/30Ostomy skin barriers and pouches (e.g., A4409/A4410) show Max Qty 10 / Max Days 30
4/30Irrigation sleeve and some ostomy supplies show Max Qty 4 / Max Days 30
1/90Certain irrigation bags and related items listed as 1 / 90 days
Common max quantity/days — typical values
10/30Common entry for ostomy skin barriers (Max Qty 10 / Max Days 30)
20/30Ostomy pouches drainable high output often show 20 / 30
Max Days typicalMany items list Max Days = 30 (typical), occasionally 60 or 90
Max quantity / days — assorted per-item limits
20/30Ostomy pouch and related items commonly show 20 units / 30 days
120/30Tape and similar consumables show higher monthly quantities (example: 120 / 30)
2/365Some items (e.g., lead wires or durable accessories) list 2 / 365
Max Qty / Max Days — per-code examples
A4558Max Qty 1 / Max Days 30 (conductive paste/gel)
A4605Max Qty 30 / Max Days 30 (tracheal suction catheter)
A4425Max Qty 20 / Max Days 30 (drainable ostomy pouch)
Max quantity / Max days — assorted per-item limits
Max Qty examplesCommon quantity values observed include 20, 30, 60, 90 depending on code
Max Days examplesMax Days entries observed include 30, 60, 90, 180, 365
RangeSome mobility/assistive items show Max Days ranges (e.g., 1–1095 for longer-term durable items)
Max quantity / Max days — common counts
12 or 30Most items list Max Qty or Max Days commonly as 12 or 30 (per-line entries)
60Some items list Max Qty 60
90Occasional items list Max Qty/Max Days 90
Max Qty — sampled values
12Example Max Qty shown for wound-care dressings and similar items
30Frequent Max Qty/Max Days value for many codes
100/200/300Higher Max Qty examples appear (100, 200, 300) for specific consumables
Max Days — common durations
30 daysMost Max Days entries are 30 days (typical supply limit)
90 daysSome items use 90 days for Max Days
180 daysCertain items list extended Max Days of 180
Max Qty / Max Days — line-level variation
12/30Wound dressings and foam dressings often show 12 / 30
4/180Compression garments and some ostomy belts show 4 / 180
100/30Consumable supplies may show 100 / 30 as a per-line limit
Typical max quantity / days — common pairings
4/180Compression stockings and related items commonly limited to 4 per 180 days
2/365Some durable accessories limited to 2 per 365 days
1/30Single-unit items often limited to 1 per 30 days
2.7% reduced purchase price — notation
2.7% reduced price presentFee schedule displays a '2.7% Reduced Purchase Price' value next to the listed purchase price for affected lines
Applied to purchase and rentThe 2.7% reduction is shown for purchase prices and sometimes rent prices
Shown alongside base priceReduced price appears adjacent to the original purchase price on each row
Max Qty/Max Days — gastrostomy/enteral and related examples
Gastrostomy/enteral examplesB4082/B4087/B4088 show purchase prices and 2.7% reduced values with Max Qty examples (e.g., Max Qty 1 / Max Days 30)
B4088Example Max Qty/Max Days = 4 / 365 for some enteral items (B4088 shows high purchase price and 2.7% reduced price)
E0157/E0158Mobility aids (E0157/E0158) include Max Qty values spanning 1–1,095 days depending on item
Max days/qty thresholds — assorted examples
1/365Some durable items and accessories limited to 1 per 365 days
1/1095Certain mobility/device components show limits up to 1 per 1,095 days
730 (days) examplesExtended rental/replacement periods shown (examples in Max Days fields up to multi-year values)
Prior Authorization, COS, LTC Pairing, and Billing Implications
Documentation Required
Prior authorization indicators in fee schedule
Fee schedule rows include explicit prior-authorization fields: a 'COS PA Req' column (shows codes such as 048 or 041 and an N/Y indicator) and a 'PA Req H/P' column with per-line Y/N flags indicating whether prior authorization or history/physical is required.
- COS PA Req entries appear as codes and N/Y (e.g., 'COS PA Req = 048', 'COS PA Req = 041').
- PA Req H/P entries show N or Y per line (e.g., 'PA Req H/P = N', 'PA Req H/P = Y').
Documentation Required
Prior authorization indicators present in fee schedule rows
Individual HCPCS rows show COS PA Req and PA Req H/P values together (for example: 'COS PA Req = 048 N' paired with 'PA Req H/P = N Y' across related lines), indicating which specific lines require PA or physician/hospital documentation.
- Example pattern: 'COS PA Req = 048 N' with 'PA Req H/P = N Y' on A4311–A4313 rows.
- Per-line pairings identify PA status for each HCPCS entry.
Documentation Required
Prior authorization and H/P indicators (excerpt)
The fee schedule displays PA Req H/P flags across consecutive lines (e.g., sequences like 'PA Req H/P = N Y N Y'), showing per-line variation in whether a history/physical or PA is required.
- Excerpted pattern: 'PA Req H/P = N Y N Y' appears in the listed rows.
Prior Authorization
Prior authorization flags (H/P)
Many entries include 'PA Req H/P = N' or similar flags; in the ostomy supply sections most lines in the extract are marked 'N' (no PA required) for PA Req H/P.
- Ostomy items (A4388–A4391 etc.) show 'PA Req H/P = N' for the majority of lines.
- Rows explicitly state PA Req H/P = N or N N for those HCPCS.
Documentation Required
COS prior authorization indicators
Some lines include COS PA Req fields that pair a code with N/Y; examples in the extract show patterns like '048 N' meaning COS code 048 with no COS prior authorization required in that line.
Prior Authorization
Prior authorization and certification indicators for ostomy supplies
Ostomy HCPCS lines in the extract commonly list both 'COS PA Req' and 'PA Req H/P' and the majority of those ostomy rows are coded with 'N' for both fields (no COS or H/P prior authorization required), with a few exceptions noted per line.
- Examples: A4388–A4391 list 'COS PA Req = 048 N' and 'PA Req H/P = N N' for many lines.
- Providers should check the specific HCPCS row because a small number of lines show differing flags.
Prior Authorization
Prior authorization indicators
The fee schedule uses COS PA Req and PA Req H/P flags at the HCPCS line level to indicate whether prior authorization or a provider/hospital PA is required for that specific code.
- COS PA Req and PA Req H/P values are provided per HCPCS line (e.g., A4425 shows 'COS PA Req = N' and 'PA Req H/P = N').
- These flags directly affect whether prior authorization steps are needed before billing.
Documentation Required
LTC pairing and alternate pricing
Many lines include an 'LTC Pair' flag; where LTC Pair = Y the fee schedule shows alternate long‑term care paired pricing and paired max-qty/days for billing in LTC settings.
- Examples: A4357–A4358 and A4396–A4397 show 'LTC Pair = Y' with LTC paired prices.
- LTC pairing changes the listed paired price and associated Max Qty/Max Days.
Prior Authorization
Prior authorization / COS codes present
Across the extract many HCPCS entries include COS PA Req codes (commonly 048 or 041) together with PA Req H/P flags (Y/N), which denote certificate-of-service or prior‑authorization requirements for specific items.
- COS PA Req examples include '048' and '041' appearing in multiple rows.
- PA Req H/P flags vary per line and must be checked per HCPCS.
Prior Authorization
Prior authorization indicators present
Multiple fee-schedule lines include both 'COS PA Req' (with code and N/Y) and 'PA Req H/P' (N or Y) per HCPCS — these indicators specify when a COS or PA is required for billing that line item.
- Examples: wound dressing and gauze lines show 'COS PA Req = 048 N' and 'PA Req H/P = N Y' across items.
- Providers must reference the specific line to determine PA/COS status.
Documentation Required
Prior authorization indicators in fee schedule lines
Per-line entries routinely include 'PA Req H/P' or 'COS PA Req' indicators (values Y or N) showing whether prior authorization or a certificate-of-service is required for that HCPCS code.
- Examples in dressing and wound care codes: 'PA Req H/P = N Y' and 'COS PA Req = 048 N'.
Documentation Required
Long-term care pairing indicators
An LTC Pair flag appears on many lines and when 'LTC Pair = Y' the fee schedule provides paired long-term care pricing which can affect billing and authorization in LTC settings.
- Examples: ostomy and nutrition lines show 'LTC Pair = Y' with paired price values.
- LTC pairing also appears alongside COS PA Req and PA Req H/P flags.
Prior Authorization
Prior authorization and certificate-of-service indicators present on line items
Groups of HCPCS lines (e.g., A6442–A6447) include both COS PA Req and PA Req H/P flags on each line, indicating when a Certificate of Medical Necessity or prior authorization is required for those items.
- Example: A6442–A6443 show 'COS PA Req = 048 N' and 'PA Req H/P = 048 N Y Y' patterns.
- Providers must check those per-line flags to know documentation/PA needs.
Prior Authorization
PA requirement for custom/compression garments
Several custom and compression garment items (A6501–A6513) are assigned COS PA Req and PA Req H/P values such as code '041' or 'Y', indicating prior authorization is required for many of these custom garment lines.
- Example: A6501–A6503 list 'COS PA Req = 041 Y' and 'PA Req H/P = Y Y'.
- A6513 and related compression codes show 'COS PA Req = 041' and 'PA Req H/P = Y'.
Prior Authorization
Prior authorization and COS flags present
Many HCPCS entries include PA Req H/P and COS PA Req flags; these per-line fields indicate whether prior authorization or a certificate-of-service requirement applies to the code.
- Examples appear across CPAP, enteral, and wound care groups where COS PA Req and PA Req H/P are recorded per item.
- Values are Y or N and vary by HCPCS line.
Documentation Required
Prior authorization indicators included per HCPCS line
Across the schedule many HCPCS lines include COS PA Req and PA Req H/P indicators in the line text (for example 'COS PA Req = 041 N 041 N' or 'PA Req H/P = N'), clarifying PA/COS requirements on a per-code basis.
- CPAP/respiratory and ostomy examples show these per-line indicators.
- Providers should use the exact HCPCS line to determine requirements.
Prior Authorization
Prior authorization and COS/PA flags present
Line items include COS PA Req, PA Req H/P and H/P LTC Pair flags together to show when a Certificate of Medical Necessity, prior authorization, or LTC‑paired billing applies for that HCPCS code.
- Enteral nutrition codes (e.g., B4153) list 'COS PA Req = 048' and 'PA Req H/P = Y'.
- Many other groups show the three flags side-by-side on the line.
Prior Authorization
Prior authorization flags included
The extract provides PA Req H/P and COS PA Req flags for many DME and supply items (values shown as N or Y and sometimes paired with COS codes like 041/048) — providers must check those per-line flags to determine if PA is required before billing.
- Per-line examples include 'COS PA Req = 041 N' and 'PA Req H/P = N N' on mobility and bathing equipment rows.
- These flags are authoritative per HCPCS line in the fee schedule.
Key Fields and Pricing Conventions (from fee schedule rows)
2.7% Reduced Price — purchase price reduction convention
2.7% Reduced Purchase Price (convention)All prices are reduced by 2.7% unless noted; fee lines show both the listed purchase price and the '2.7% Reduced Purchase Price' value
Displayed per-rowWhen present the reduced price is shown adjacent to the purchase (and sometimes rent) price for that HCPCS line
Affects purchase and rentReduction applies to purchase prices and, where shown, to rent prices as well
Medicare Covered** — flag presence and meaning
Medicare Covered** flagRows include a 'Medicare Covered** Purchase' indicator (Y/N) showing Medicare purchase coverage status per item
When YIf 'Y' is present the associated Medicare purchase price is displayed on the row
When NWhen 'N' no Medicare purchase price is listed for that item in the extract
2.7% Reduced Purchase Price / Rent Price — repeated convention
2.7% reduced purchase/rent (repeated)Many rows show a 2.7% reduced purchase price and sometimes a reduced rent price displayed alongside the base values
Shown where applicableReduced rent values appear on rows that include rent pricing; otherwise only purchase reduction is shown
Consistent formatThe extract uses the same notation 'Price 2.7% Reduced Purchase Price' across multiple segments
Medicare Covered** Purchase — flag and asterisk convention
Medicare Covered** purchase (display)When 'Medicare Covered** Purchase = Y' is present the row includes the Medicare purchase price and the reduced purchase price value
Affects billing displayThe Medicare Covered indicator is shown per-line and influences which purchase price is reported
Asterisk conventionThe document uses '**' next to 'Medicare Covered' label in the fee schedule extract
COS PA Req / PA Req H/P — column definitions
COS PA Req'COS PA Req' column shows Certificate-of-Service / prior authorization requirement codes (examples include '048' and '041')
PA Req H/P'PA Req H/P' indicates whether prior authorization is required for hospital/physician or home/provider contexts (values Y/N)
Used per-rowBoth flags appear on each HCPCS line to indicate documentation/authorization requirements
2.7% Reduced Price — additional instance
2.7% reduced price (instance)The '2.7% Reduced Purchase Price' column is used repeatedly to show adjusted fee schedule prices for listed items
Applied broadlyThis reduced-price column appears across many HCPCS ranges in the extract
Shown alongside Medicare priceWhere Medicare purchase price is shown the reduced price is displayed in relation to it
Medicare Covered** — purchase indicator and associated prices
Medicare Covered** (purchase indicator)Indicates whether Medicare covers the purchase; when 'Y' the Medicare purchase price is shown and a reduced price is displayed
Per-row usagePresent on many fee lines across code groups in the extract
Affects displayed price fieldsControls whether Medicare-specific purchase price values are shown on the row
2.7% Reduced Purchase/ Rent Price — standardized application
2.7% reduced purchase/rent (standard)A standardized 2.7% reduction is applied to purchase (and sometimes rent) prices; reduced values are listed on fee lines
Notation used repeatedlyThe extract repeatedly annotates rows with 'Price 2.7% Reduced Purchase Price'
LTC pairing presentSome lines also show LTC-paired prices alongside reduced prices
LTC Pair — long-term care pairing indicator
LTC Pair'LTC Pair' indicates long-term care pairing and shows paired price values (e.g., rows show 'LTC Pair = Y' with an LTC price)
Paired price displayedWhen LTC Pair = Y a paired LTC price is often shown next to the purchase price
Affects billing in LTC settingsIndicates alternate pricing when billed in long-term care contexts
PA Req H/P — prior authorization (H/P) indicator definition
PA Req H/P (definition)Prior authorization required for hospital/provider or home/provider contexts; values shown as Y or N on each line
COS PA Req (definition)Certificate-of-Service prior authorization code column (examples '048' or '041') indicating PA/documentation requirements
Per-line flagsBoth fields appear per HCPCS row to denote authorization or documentation requirements
Medicare Covered Purchase — definition and display
Medicare Covered Purchase (display)When 'Medicare Covered** Purchase = Y' the row includes the Medicare purchase price and the reduced purchase price values
Shown per-codeDisplayed on individual HCPCS lines where applicable
Affects payer billingDenotes Medicare coverage status per item for billing reference
LTC Pair — typical values and usage
LTC Pair (typical values)Typical LTC Pair entries show 'Y' with a paired LTC price (e.g., $40.41 for an ostomy belt)
Shown alongside purchase priceLTC paired price appears adjacent to the standard purchase and reduced purchase prices
Used across code rangesLTC Pair flag appears in many HCPCS groups in the extract
Medicare Covered / Purchase — field pairing
Medicare Covered / Purchase pairingRows may display both a Medicare-covered purchase price and the standard purchase price with the reduced purchase price noted
Helps identify Medicare-eligible itemsThe presence of 'Medicare Covered** Purchase = Y' marks items considered covered by Medicare
Displayed consistentlyThis pairing appears across multiple HCPCS ranges in the fee schedule extract
COS PA Req / PA Req H/P — ostomy-row column definitions
COS PA Req / PA Req H/P (ostomy rows)These columns appear on ostomy supply rows showing whether a Certificate of Service or H/P prior authorization is required (most are 'N')
Check specific rowProviders should reference the specific HCPCS line for its COS/PA/H/P flags
Examples presentOstomy rows include examples of '048 N' and 'PA Req H/P = N' across many entries
LTC Pair — short definition
LTC Pair (short)Indicator that the item pairs with long-term care billing and may show a paired price
Values: Y/NShown as 'Y' when paired; paired price value appears on the row
Impacts billing settingIndicates alternate billing/pricing in LTC settings
COS PA Req — component-of-service prior authorization field
COS PA Req (definition)'COS PA Req' denotes Certificate of Service / prior authorization requirement (codes like 048, 041 may appear)
Appears per-lineThis field is present on each HCPCS line to indicate PA/certification requirements
Used with PA Req H/PInterpreted together with PA Req H/P to determine authorization needs
PA Req H/P — prior authorization (H/P) definition (instance)
PA Req H/P (definition instance)Indicates whether prior authorization is required for hospital/physician or home/provider contexts; values Y/N shown per HCPCS line
Used with COS PA ReqEvaluated together with COS PA Req to determine documentation/PA requirements
Shown across code groupsPresent for compression garments, CPAP supplies, ostomy items, enteral supplies, etc.
2.7% Reduced Purchase Price — repeated definition
2.7% reduced purchase price (repeated definition)The '2.7% Reduced Purchase Price' column denotes the adjusted fee schedule price and is shown adjacent to the listed purchase price
Applies widelyThis notation recurs across many HCPCS ranges in the extract
Also shown for rent when applicableReduced rent price displayed when rent price is present on the row
Medicare Covered Purchase Price — definition and display
Medicare Covered Purchase Price (definition)When 'Medicare Covered** Purchase' is present the row shows the Medicare purchase price and reduced purchase value
Displayed per codeAppears on individual HCPCS rows where Medicare purchase coverage applies
Used for billing referenceHelps identify Medicare-eligible purchase pricing
Medicare Covered** — presence and implication
Medicare Covered** (indicator)Indicator present next to many items showing whether Medicare covers the item (Y/N) for purchase
When Y shows priceIf 'Y' is present, the Medicare purchase price is provided on the line
Widespread in extractThis indicator is used across many HCPCS ranges in the schedule
2.7% Reduced Purchase/ Rent Price — derived price column
2.7% reduced purchase/rent columnA derived price column applies a 2.7% reduction to the listed purchase price for items; the reduced value is shown on the fee line
Consistent notationLabel 'Price 2.7% Reduced Purchase Price' appears consistently across the extract
Also reduces rent where applicableRent prices are reduced by 2.7% when rent is present on the row
COS PA Req — codes and examples
COS PA Req (codes)COS PA Req column contains codes like '048' or '041' on some lines to indicate specific PA/certification requirements
ExamplesEntries show COS PA Req = 048 or 041 for many codes (see compression garments, ostomy supplies)
Interpreted with PA Req H/PUsed together with PA Req H/P to determine authorization/documentation rules
2.7% Reduced Purchase Price — adjusted fee schedule price
2.7% Reduced Price (definition)The 2.7% Reduced Purchase Price is noted as the adjusted fee schedule price for items where shown
Applied to many itemsThis adjusted price column recurs across the fee schedule extract
Displayed beside original priceReduced price appears adjacent to the original purchase price on the row
COS PA Req / PA Req H/P — administrative flags definition
Administrative flags (COS PA Req / PA Req H/P)COS PA Req and PA Req H/P flags denote whether a Certificate of Medical Necessity or prior authorization/health plan approval is required for the HCPCS item
Examples presentFlags like '048' and '041' appear across code groups; PA Req H/P values are Y/N per-line
Used for provider actionsProviders should consult these flags when submitting claims or requesting authorization
LTC Pair — indicator and paired price
LTC Pair indicator (definition)Indicates whether the item pairs with long-term care billing and provides a paired LTC price when 'Y'
Paired price shownWhen present a paired price value (LTC price) is shown on the row next to the purchase price
ImplicationSignifies alternate billing/pricing for LTC settings
PA Req H/P — prior authorization required for home/particular place
PA Req H/P (prior auth for home/provider)Flag indicating whether prior authorization is required for home or provider settings; values shown as Y or N per line
Used with COS PA ReqInterpreted together with COS PA Req to determine documentation/PA needs
Appears across rangesPresent on many HCPCS lines including CPAP, enteral, ostomy, and compression items
Long-term care pairing indicator — yes/no and paired price
LTC Pair (yes/no + price)LTC Pair presents as Y/N; when Y an LTC paired price is shown (e.g., '$40.41')
Alters billingIndicates alternate reimbursement when billed in long-term care settings
Frequently usedThe LTC Pair flag is used across many ostomy and DME entries in the extract
2.7% Reduced Purchase Price — blanket statement
2.7% reduction applied on fee scheduleFee schedule shows a 2.7% reduction applied to purchase (and sometimes rent) prices; reduced price values are listed per line
Document conventionThe header notes 'All prices are reduced by 2.7% unless noted' and rows repeat the reduced-price column
Affects purchase and rentBoth purchase and rent fields reflect the reduction where applicable
PA Req H/P — definition instance
PA Req H/P (instance)PA Req H/P denotes whether prior authorization is required for hospital/physician or home/provider contexts; values are shown per HCPCS line
Referenced in many linesUsed across compression garments, CPAP, ostomy, enteral and other code ranges
Check per-codeProviders should verify the PA Req H/P value on the specific HCPCS line for authorization needs
COS PA Req — definition instance
COS PA Req (instance)COS PA Req indicates Certificate-of-Service/prior authorization requirement codes (e.g., 048, 041) per HCPCS line
Interpreted with PA Req H/PUsed with PA Req H/P to determine if PA or documentation is required
Appears on many rowsCommon across ostomy, wound care, compression and other DME items
LTC Pair / Pair — short definition
LTC Pair / Pair (short)Short definition: indicates long-term care pairing and paired price when present
Displayed as 'Y' with priceWhen paired, rows show 'Y' and the paired price value
Used widelyPresent across many HCPCS ranges in the extract
COS PA Req and PA Req H/P — combined flags meaning
COS PA Req & PA Req H/P (combined use)These flags denote whether a Certificate of Medical Necessity or prior authorization/health plan approval is required for the HCPCS item — check both fields on the row
ExamplesCodes like '048' or '041' in COS PA Req and Y/N in PA Req H/P indicate specific PA requirements
Action for providersConsult the HCPCS line's COS PA Req/PA Req H/P values when preparing prior authorization or documentation
Medicare Covered** Purchase — instance
Medicare Covered** Purchase (instance)Indicates whether item is considered covered by Medicare and displays associated purchase prices when 'Y'
Displayed per-lineUsed throughout the fee schedule extract to denote Medicare purchase coverage
Affects price fieldsControls display of Medicare-specific purchase pricing and reduced values
COS PA Req / PA Req H/P — paired field definition
COS PA Req / PA Req H/P (field pair)'COS PA Req' and 'PA Req H/P' are prior-authorization or plan-specific requirement indicators included on each HCPCS line to denote PA/documentation needs
Typical valuesCOS PA Req shows codes like '048'/'041'; PA Req H/P shows Y/N per item
Used across code groupsPresent in ostomy, wound care, compression, enteral, and other DME ranges
2.7% Reduced Purchase Price — blanket convention
2.7% Reduced Purchase Price (blanket)Header states 'All prices are reduced by 2.7% unless noted' — a blanket reduction applied to listed prices
Document-level conventionThis is a document-wide pricing convention reiterated on rows via 'Price 2.7% Reduced Purchase Price' fields
Apply unless notedReduction applies unless an exception is specified on the fee line
COS PA Req / PA Req H/P / H/P LTC Pair — administrative flags
Administrative flags (COS PA Req / PA Req H/P / H/P LTC Pair)These administrative flags indicate Certificate-of-Service/prior authorization requirements, whether prior authorization requires history/physical, and long-term care pairing — present per line item
ExamplesRows show combinations such as '048 N' for COS PA Req and 'PA Req H/P = N' or 'Y' depending on item
Provider implicationUse these flags to determine documentation and authorization steps when billing
Medicare Covered** — definition instance
Medicare Covered** (definition instance)'Medicare Covered**' indicates Medicare purchase coverage status per item and is shown on many fee schedule rows
Displays purchase priceWhen present the Medicare purchase price and reduced purchase price are shown
Used across code rangesApplied to ostomy, enteral, CPAP, wound care and other DME entries
2.7% Reduced Purchase Price — final definition instance
2.7% Reduced Purchase Price (final instance)Final reiterated instance: the fee schedule applies a 2.7% reduction to purchase (and sometimes rent) prices; reduced values are listed per row
Consistent across fileThis reduction and the reduced-price field are used consistently in the extract
Check row for exceptionsRows that omit reduced-price values indicate either no price or an exception
Policy Summary
PayerIllinois Department of Healthcare and Family Services
PolicyDurable Medical Equipment and Supplies Fee Schedule
Policy CodePolicy N/A
Change TypeAdministrative fee-schedule update (no material clinical coverage changes)
Effective DateJan 1, 2026
Last ReviewApr 1, 2026
Next Review DateApr 1, 2026
Key ActionWhen billing HFS for DME/supplies, reference each HCPCS line for its purchase/rent price, Max Qty/Max Days, Medicare coverage flag, and COS/PA H/P indicators.
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